ERISA Claims: What You Need to Know If Your Health Plan Is Through Your Employer

December 22, 2024

Managing Your ERISA Claim Can Be a Formidable Process

Do you have insurance through your labor union or private sector employer insurance plan? If so and you have become ill or even disabled due to a serious illness or the impact of an injury, you may be able to file an ERISA claim for benefits.

As you are well aware, the cost of medical care  can be considerable, and these expenses are only the tip of the iceberg when considering your future.  If you are disabled or so seriously ill that you are unable to return to work for a period of time or permanently, the financial impact on your life can be devastating. You may have coverage that can help alleviate these expenses.

Unfortunately, filing, appealing, and litigating ERISA claims and obtaining the benefits to which you are entitled can be challenging.

Contrary to what your insurance company may lead you to believe, their goal is to minimize  your settlement and maximize their profitability.

In times like this, the value of an insurance attorney who is well-versed in ERISA law, managing the ERISA claims process, and successfully advocating for those whose claims have been denied can be incredibly valuable. It may make sense to reach out to an Oklahoma ERISA insurance claims attorney for advice and counsel.

What Is ERISA?

Understanding the definition of ERISA is important. In 1974 Congress passed the Employee Retirement Income Security Act, better known as ERISA.  This was designed to offer protection for individuals and their families who are covered by employer insurance plans, including health, disability, life, and pension.

It is important to recognize that the majority of employer-provided insurance plans are subject to ERISA law. That said, those who work directly for the government (state, federal and local) are generally not offered protection under ERISA, but they may be if they have benefits provided by their labor union.  Finally , religious organizations like churches are exempt from ERISA.

Information regarding your exact coverage can be found in the summary section of your plan; reviewing this documentation prior to moving forward with any type of claim or complaint is paramount.

Understanding ERISA Claims

ERISA claims are confusing; that is why many reach out for professional legal assistance when submitting, managing, or disputing them.

As an employee, having insurance that must comply with ERISA benefits you. In all cases you should understand your policy coverage and determine whether you are eligible to file a claim.  Your plan may invoke a waiting period during which you are not eligible for benefits, regardless of your level of illness, injury, or disability.

Once you determine your coverage, you should gather necessary information (including medical records) and file your claim with your plan administrator, according to their specifications. If your claim is denied, ERISA provides you with the opportunity to submit an appeal.

Plans that are covered under ERISA must act in the best interests of their participants.  When they don’t, participants are guaranteed the right to appeal and, if necessary, bring a suit to federal court due to breach of duty.

The ERISA Appeals Process

If you receive a letter of denial in response to your ERISA insurance claim, all is not lost.  In fact, under ERISA law, you have the option to appeal. At this point, engaging experienced legal counsel may be in your best interests. This professional will help identify the reason for denial and ensure your appeal is filed in accordance with the rules and regulations of your carrier under ERISA law.  The process is purposefully complex and time consuming. Individuals filing these claims are often managing a traumatic change in their lives. Recovery is physical and emotional; they simply don’t have the knowledge, experience, or bandwidth to bring an appeal successfully. Help is available. Your attorney will:

• Review all information including your policy, your claim submission, and the insurance company denial letter
• Assist in gathering all relevant documentation including medical records
• Draft your appeal letter, ensuring it addresses all reasons for denial and accurately depicts your medical condition and its impact on your life and ability to return to work.

It is critical to abide by ERISA appeal deadlines.

Under the law you have 180 days from the date of denial to submit your internal  appeal, your first course of action.

Inquiries after this date will not be reviewed. Internal appeals are conducted by the plan administrator.  If your internal review is unsuccessful, you can request an external review by an Independent Review Organization (IRO).  In cases where you are still unable to affect an acceptable outcome, you can pursue legal action in federal court. Your ERISA insurance claims denial lawyer can help you evaluate all actions.

Tips for Filing ERISA Claims

ERISA covers a broad range of plans including those relating to insurance (health, disability, and life) and even pensions.  While each type of insurance claim is unique, there are some things policyholders can do that increase the chances of claims being paid or appeals upheld. These include:

• Adhere to ERISA deadlines with regard to initial claim submissions, appeals of denials, and filing federal lawsuits
• Correspond with your insurance company in writing so you have a paper trail of all communication
• Gather and submit complete claims that include all medical records, notes from your physician, and copies of correspondence with insurance company representatives
• Identify and engage an experienced and reputable ERISA claims denial attorney
• Draft and submit detailed appeals letters that address the insurance company’s reasons for denials as stated in their letter to you
• Include additional information in your appeal (including research, supporting information from your physician, etc.) that supports your claim.

Engaging a seasoned and reputable ERISA attorney who can help you navigate this process can increase your chances for success.

How Can an ERISA Attorney Help?

Doug Terry Understands ERISA Law and the Claims Process

Because of the time-consuming nature of the ERISA appeal process and the complexities inherent in ERISA law, engaging an experienced attorney can make a very real difference both in the success of your appeal or lawsuit and the quality of your life during the process.  Because this professional will assume responsibility for the entire appeal/legal process, as well as any associated legal action, you will have time to focus on your life and your recovery.

Led by Doug Terry, Doug Terry Law is well-versed in ERISA law and has decades of experience representing individuals who have struggled with ERISA insurance claim denials. They understand the stress associated with the appeal and litigation processes and are well-known for their empathetic approach to service.

Contact Doug Terry Law Today for Help with Your ERISA Claim

Successfully submitting, appealing, and litigating your ERISA claim is important; you need the compensation from your insurance company to live your life. Medical and disability expenses can be astronomical and managing that debt without the help of insurance is devastating.

At Doug Terry Law we recognize the stress you are under and appreciate your need for assistance with the ERISA insurance process. We know how to handle ERISA claims, ERISA appeals and lawsuits effectively. Because we appreciate the importance of adhering to all timelines, we encourage you to reach out to us as soon as possible.

Part of our commitment to our clients includes the provision of a no-cost consultation. This meeting provides us with the opportunity to learn more about your situation and your needs and offers you the chance to not only hear how we would approach your case, but also see, firsthand, how we interact with our clients.

We take the responsibility of representing you seriously. As your attorney, we adopt your goals as our own and work tirelessly to maximize your settlement.

Are you having issues with your employee-sponsored insurance plan?  If so, contact us at 405-463-6362 to schedule your free consultation.  ERISA law is aimed at protecting you as a policyholder and provides you with specific avenues for appeal. We are ready to pursue them on your behalf.